MR FLAIR
Claim CME CreditPOINT OF CARE INFORMATION
This CME activity consists of the student reviewing the video of the professor reviewing the case as well as the associated DICOM image set related to the case in question.
Learning Objectives
As a result of participation in this activity, participants should be able to:
- Provide improved patient care.
- Greater knowledge of the imaging characteristics of the patient's disease.
- Understand a better approach to interpretation of studies.
Faculty Disclosure
Mehmet Albayram, MD, Ivan Davis, MD, Mariam Hanna, MD, Anthony Mancuso, MD, Ronald Quisling, MD, Dhanashree Rajderkar, MD, Priya Sharma, MD, Roberta Slater, MD and Joann Stamm, MBA have disclosed that they have no relevant financial relationships. No one else is a position to control content have any financial relationship to disclose.
CME Advisory Committee Disclosure:
Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/.
Continuing Medical Education Credit
Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CA0592-MR FLAIR
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CA0592-MR FLAIR
Case ReportExam
Prior Study
There is evidence of aggressive right otomastoiditis with sigmoid plate dehiscence (coalescent otomastoiditis) producing a small volume, epidural abscess, which partiall compresses the adjacent dural sinus. Focal deformity of the sigmoid sinus is evident at the site of epidural abscess, however, the remaining lumen of the right sigmoid sinus and the internal jugular vein are patent. Intraluminal thrombus is present in the torcular herophile, the left transverse/sigmoid sinuses, extending into the high cervical left IJ.
CT perfusion: No CT perfusion is available
CTA of the neck
Thrombosis of the high cervical left internal jugular vein with collateral drainage into the other left neck veins. The right IJ is patent. No soft tissue abnormality is evident within the cervical soft tissues.
MRV of the head
Segmental thromboses in the dural sinuses, especially in the superior sagittal sinus (SSS) and in the left transverse sinus. Major veins in the opacified (non thrombosed) SSS segment are patent and exhibit re-routing patterns. Persistent impression remains adjacent to the small epidural abscess adjacent to the right sigmoid plate.
Post contrast CT for analysis of the venocapillary pool
There are known multiple dural sinus thromboses that are underestimated on the delayed post contrast CT.
There is no evidence of reduced CT density within the venocapillary pool in either the cerebrum or cerebellum.
There is evidence of both optic hydrops and early hydrocephalus related to venous hypertension caused by the dural sinus egress block. It is concievable that the hydrocephalus could be in part related to meningitis associated with the right coalsecent otomasoiditis.
MR T1-w post contrast
Partial improvement In the extent of dural sinus thromboses likely related to improved venous collateral egress and/or progressive recanalization with improved antegrade blood flow. Persistent right otomastoiditis and epidural abscess; the size of the abscess has gotten smaller with treatment. Some reduction in the degree of ventriculomegaly likely related to improved venous egress with reduction in CSF pressure.
MR diffusion
There is evidence of positive MR diffuson in the site of coalscent mastoiditis with epidural abscess on the right plus evidence of a very small recent embolic arterial stroke in the left superior vermis.
Findings
MR FLAIR
There is positive FLAIR signal along the surface of the brain and diffusely within sulci/cisterns both in the posterior fossa and supratentorial areas consistent with meningitis or at least meningeal inflammation. There is abnormal FLAIR signal in the right temporal bone coalescent otomastoiditis. There is minimal thickening of the dura throughout the head, again an expected finding in meningeal inflammation/ infection but also is elevated CSF pressure.
There is a small area of parenchymal positive FLAIR in the same area of the left superior vermis consistent with acute ischemic event. However, whether this is on a venous or embolic arterial basis is indeterminate.
There is subtle transependymal positive MR FLAIR confirming early hydrocephalus. The same findings could be related to inflammatory/infectious ventriculitis, especially in the context of coalescent right otomastoiditis.
There is diffuse paranasal sinus mucosal thickening without aggressive features.
There is asymmetry in the flow related signal void between the patent right transverse sinus and right channel of the torcula compared to the increased FLAIR signal in the left channel of the torcula and proximal left transverse sinus. FLAIR is often not very helpful in determining patency of arteries or veins, however in this case the asymmetry between the right and left dural sinuses represents a potential positive FLAIR finding in dural sinus thromboses.
Impression
2. Persistent subtle ventriculomegaly with minimal persistent transependymal fluid migration.
3. Punctate area of positive FLAIR signal in the left vermic area matches the MR diffusion positivity in the same area consistent with stroke. But whether this is a venous or arterial embolic stroke is indeterminate.
4. Complete loss of the usual flow-related FLAIR signal is evident in the right transverse/sigmoid sinuses, the torcula, and distal SSS consistent with thrombus (signal loss likely on basis of hihg deoxyHgb levels).
5. Interval development of paranasal sinus mucosal thickening, currently without aggressive features.
Recommendations
Proceed to the summary video and case report to view all of the imaging findings in this case plus the "Lessons to be learned" from this specific instructional case.
